Basic Information
| Provider Information | |||||||||
| NPI: | 1336540798 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SKYLARK ASSISTED LIVING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 SKYLARK PL | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975209640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415521713 | ||||||||
| FaxNumber: | 5415521058 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 SKYLARK PL | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975209640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415521713 | ||||||||
| FaxNumber: | 5415521058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2014 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | WOOLLARD | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5415521713 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 1121496081 | OR | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 502827 | 05 | OR | MEDICAID |